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Please check one: <br /> New Addition <br /> JOB SITE e h Br-CIS <br /> Owner's Name 5a,__.;ne..- Telephone Number <br /> Mailing Address d <br /> Sprinkler Contractor's Name Telephone Number LI ]� j� 'I <br /> p M.c7' K.h/�t�t-Vl �(�S P -L ,� l � l � `c7 <br /> Contact Person v -F- 'c, E_f( <br /> Mailing Address ) q(0 3 0 C-t c,y �5 1 i-nclig- 1 14/1/ 67c30 7 <br /> l <br /> WATER SUPPLY <br /> Lake Well 9City <br /> BACKFLOW DEVICE / <br /> AVB PVB �/ <br /> Year of <br /> Make Model Manufacture Quantity <br /> Sprinklers <br /> 'ye-)vc 5 76 97 ___N <br /> .area a g 7� - <br /> 1 ©vro CC <br /> �l „o ir0 �5. I 'mooro `1 i S t`o)1 TOTAL 9c <br /> DRkIILIC FALCULAT ONS Design Data (° Ccs{-- , p rpp i'-',9( <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: 45 ' 40 Sq. Ft. <br /> I No. of Sprinklers: Q <br /> Total Water Required: G3 "70 GPM <br /> PERMIT FEE CALCULATION I <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ 6 8 <br /> �� <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to <br /> do all work in strict accordance with the ordinances of the City and State regulations, and certifies <br /> that all statements made on t'is appy tion are complete, true and correct. <br /> Applicant/ , ��ti.. Date /5 7 <br /> ******* ,***. ***.****...,...**..*....**.*.... * ..***********..*.*.*.***..... <br /> Approved Approved with Corrections Denied <br /> Reviewed by. <br /> --7?- /C./�'�y Date -S----/3 7 <br />